A Message against Neglect

Harm reduction programs are facing a serious threat of being closed unless finances for future sustenance and development are allocated from the Budget of the Republic of Macedonia. If this happens, many people will lose the only health, social and legal support they receive in this state, with consequences resonating throughout the society. This is far from just our personal opinion. The staff at the City of Skopje, Department for Social, Child and Health Protection agrees. We asked Eleonora Panchevska Nikolovska about her personal views on the advantages of harm reduction programs for the protection of public health and the potential disadvantages in case of closure.

Eleonora Panchevska Nikolovska is the head of the Department for Social, Child and Health Protection at the Sector for Public Activities in the City of Skopje. She is also the coordinator of the Coordinative Body on Drugs of the City of Skopje, founded in 2007, with representatives from the Skopje municipalities, institutions, civil society organizations and religious organizations concerned with drug issues. The Coordinative Body developed the two consequent strategies on drugs of the City of Skopje.

Harm reduction programs have been active in Skopje since 1996, contributing to HIV protection of the local population and human rights advocacy. What is the City’s cooperation with the harm reduction programs, and to what degree, in your personal opinion, do such programs help the city’s efforts for promotion of citizens’ health?

When the local decentralization was launched, in 2005, we started developing the programs for social protection of marginalized groups which, in fact, meant gradual introduction to the problems these citizens faced. Regarding the issue on people who use drugs, we perceived the necessity for different programs, among them the Harm Reduction Programs.

Acting as a local self-government unit, we concluded that our biggest responsibility and competence lies in preventive health protection with a focus on drug prevention. However, from a strategic view point, it implied only one segment of drug policies, thereby disregarding other segments crucial for solving the drug issue such as: treatment, harm reduction, re-socialization, rehabilitation and other important fields. From a harm reduction aspect, we observed the need for several programs, i.e. people who use drugs do need support but primarily need sterile equipment, medical as well as legal aid. And of course, most importantly, we needed to reach and possibly motivate them to volunteer in the programs for addiction treatment. Basically, all listed aspects and drug policies areas are very important, with harm reduction being an inextricable part of these policies.

The results the centres achieved were difficult to disregard, i.e. the number of clients annually, their satisfaction, anonymity and confidentiality during contact, the number of people sent to treatment and particularly the lowest rate of people living with HIV in the region.

Are harm reduction programs part in the City’s policies and in what way?

Regarding the City’s drug policies, we should mention the Strategy on Drugs, as well as the Strategy for HIV Protection. These strategies cover strategic areas such as prevention, harm reduction, re-socialization, rehabilitation, safety in the city. The city of Skopje aims to support the priority programs in each of these areas.

For instance, we support prevention programs, i.e. we opened a Drug Prevention Counselling Centre for high school students and other age groups who require counsel. Prevention programs are being implemented in highs school within the City’s jurisdiction. Furthermore, the City also offers support to the Day Re-socialization and Rehabilitation Centre for People who Use Drugs, as well as other programs for prevention and information, such as the HIV and drugs hotline. There is also the City’s support to one of the day harm reduction centres.

We develop programs for different target groups, which are also interrelated. For instance, an individual who receives help in the day centres can contribute towards harm reduction among the general population or simply just help another individual in terms of HIV prevention but also other blood-borne and sexually transmitted diseases.

Have you ever assessed the results from the city’s support of these programs?

Information on the number of clients visiting the day centres, the clients referred to further treatment, not only regarding harm reduction but also re-socialization, rehabilitation and prevention is important. More specifically, we need to know the number of citizens directly affected with the drugs policies. The results are quantitative, but equally important are qualitative indicators on these citizens’ needs, how content they are with the services, how their families accept the programs, as well as their future expectations. In my opinion, such information is crucial and reveals how relevant the programs are to these citizens.

What is the public’s reaction to such drug policies?

In my experience the public has been supportive. I refer here to the decision-makers who adopted the strategies, participated in their development, and extended their support to the Mayor’s Cabinet. In all honesty we did receive support. When we started in 2007, we were very sceptical and expected a backlash of disapproval, objections, stereotypes and prejudices. We did run into resistance during the discussions, after all, everyone had the right to participate in the strategy development and share their opinion, and some were intolerant of drug users. However, we didn’t encounter significant opposition or obstructions from decision-makers or citizens not directly concerned with this issue but who have formed an opinion on it. The same occurred when the centres were opened. Of course, the issue of sufficient finances for the following year is ever-present. However, once this issue was covered with the Program for Social Protection, the programs have been regularly realized and financed without any obstacles.

We are very well aware of the reactions triggered with the opening of the drug treatment day centres. The Ministry of Health faced a serious problem expanding the capacities of the Addiction Treatment Centre in Kisela Voda. The Council members of certain municipalities relayed the strong reactions of citizens who opposed the decision and obstructed the opening of such centres on certain locations. However, clear policies and precise goals preclude any obstacles, from politicians or the general population.

In July 2017, the support for HIV and tuberculosis prevention within the harm reduction programs from the Global Fund is coming to an end, with the risk that the programs might be closed. What would the closure of harm reduction programs imply for the City of Skopje?

This would pose a serious problem from a health, social and family aspect for the many concerned citizens. From a general perspective, there is the risk from infectious diseases and increased drug use. In addition, we will lose the possibility to monitor and have insight in the situation on the field. People won’t be able to access other programs, and this vicious circle will mostly affect the concerned citizens but also the broader community as well. This would generally lead to negligence. On the one hand, people will face specific social and health problems, and on the other, instead of maintaining and promoting the current quality of functioning programs that bear results, they will be shut down. It sends the wrong message – lack of concern towards the citizens affected with the programs.

The City of Skopje continues its support of many programs through the social protection programs in 2017 as well. Such are the programs for prevention, rehabilitation, re-socialization etc. The strategies on HIV and drugs can also encompass other activities as well as organizations which can apply to the City’s open call. We have always been open to all forms of support and I believe we will continue to do so in future. The closure of the programs will impact the Program for Social and Health Protection, i.e. the significant support the City offers will not suffice and without the finances received from the Global Fund, the Ministry of Health or other sources the achieved results will be difficult to copy. The City’s role is more towards promotion of the programs. I fear that in this case, relying on one source will not produce results. Of course, the City will continue its financial support, however, the effects will resemble a drop in the ocean.

Although we developed the City’s HIV and drug strategies on the principle of shared responsibility, we failed to motivate other local and national institutions to adopt the same model. Unfortunately, the City has been the only supporter this entire time, despite our efforts to share information and offer examples on the practical application of our experiences in other municipalities and institutions in Skopje. These activities never found their place in the budgets of other institutions. We are yet to see an institution following in our footsteps, in other words, shared responsibility in financing the programs, so necessary for the citizens’ wellbeing, is still missing.

How can such cooperation and support be provided?

We definitely need better coordination, among decision-makers but also among the staff in the municipal departments for social protection and the competent institutions. This has to be a priority issue in the programs for social and health protection. However, the Ministry of Health and Ministry of Labour and Social Policies are crucial to these issues and should take the lead in the implementation of harm reduction programs and participate with larger finances. Social and health policies in general are hardly present in municipalities and are believed to be either in the jurisdiction of the ministries or the City, i.e. certain municipalities avoid complete responsibility. Therefore, apart from coordination, we require education on the legislation and its interpretation. The laws are favourable and offer the municipalities the opportunity to be included. Local self-government units have no jurisdiction in the treatment, however in terms of social care, the City of Skopje with its municipalities do have the opportunity to take part and contribute in this issue.